Ask The Expert



Ask The Expert
Ask The Expert
Published on OBGYN.Net (
Ask The Expert
May 18, 2006 | Menopause [1], Integrative Medicine [2], ObGyn Nurses [3], Contraception [4], Sexual
Health [5], Pregnancy and Birth [6], Pelvic Pain [7], Incontinence [8], Infertility [9]
By Ronald Barentsen, MD, PhD [10]
Am I experiencing Perimenopause? What should I expect from HRT?
Am I experiencing Perimenopause?
What should I expect from HRT?
Doctor, Are these symptoms of Menopause?
Q: I am 47 years old, Caucasian, and generally in good health. I plan to have a hysterectomy for
grapefruit-size fibroids, which are causing general discomfort and . Is there any value to natural
menopause over surgical menopause, assuming the ovaries are not diseased? I think this would be
an easier decision for someone who is post-menopausal. I have had about half a dozen hot flashes
over the last year and seem to be experiencing more joint pain than usual. My menstrual cycle has
been a predictable 25 days for several years.
A: Do not remove normal ovaries. With surgical menopause (removal of both ovaries), a sudden decrease of estrogens occurs with a lot of vasomotor complaints and more bone loss than with natural menopause. Also the ovaries produce androgens, and androgens are important for libido. The production of androgens is maintained until very old age. Postmenopausal ovaries are still functioning organs.
Q: My wife and I are both 52. She went through menopause 3 years ago, but we are still concerned
about the possibility of getting pregnant. Could you refer me to some information on this issue?
A: 3 years after menopause the possibility of getting pregnant is essentially zero. When still menstruating after 50 the possibility of getting pregnant is extremely small.
Q: I am 56 years old and have always had "normal" periods. This past Dec. I had my last period. I do
not get hot flashes or any other menopause symptoms. However, I have cramps, not severe but a
pressure feeling and cramps. I keep thinking I am getting my period. Is this normal for this time of
A: I suppose that there is still hormonal activity from your ovaries and you are aware of the effect on the uterus. Maybe a new bleeding is coming.
Doctor, am I experiencing Perimenopause?
Q: I am a 41 year old women who has experienced changes in her period for the past year, some
short some long, however 5 weeks ago I started my period and it was light for 2 days then heavy for
about 5. It then continued in a light flow for another 2 weeks. Then it stopped for exactly 1 week and
started again, it was very heavy for the next 7 days, I was changing a every hour, for several days
then it slowed a bit. I also experienced lower pelvic pain as well as lower back pain, typical of a
period but became bothersome after the first week. Total I had a period for 3 weeks straight stopped
one week and started for a total of 4 out of 5 weeks of menstrual flowing. My period has stopped for
2 weeks, however I am still experiencing some pelvic pain as well as lower back. Any ideas or
suggestion as to what may be happening?
A: This is certainly an unusual menstrual pattern that deserves further attention. This is not a perimenopausal pattern.
Please check-out this great article on your question called, "Perimenopausal Bleeding - what's normal?" by Paul D. Indman, MD, Editorial Advisor.
Q: I am 49 with hot flashes, periods about every 3 months, and my hypertension is fairly well
controlled most of the time. My doctor has given me some low dose pills but I am afraid to take
them for fear that they will raise my blood pressure. Is there any chance I could take HRT at this
point? I think that the lower dose of estrogen will be less of a problem with my blood pressure. I
don't have a need for contraception. What do you think?
A: Low dose BCP are excellent in this phase of life. The risk of increasing blood pressure is very low with the low dose pill and it occurs in the first 3 months, so it is easy to detect. An other possibility is HRT. But in this phase of perimenopause with HRT bleeding problems are seen often. Especially with continuous combined HRT. The best is sequentially combined HRT: continuous estrogens and 10-14 days each month progestagens. When cycle is not perfect with this form of HRT, usually the amount
of progestagens has to be increased somewhat.
Q: I am 48 years old and have had irregular periods for 2 years. When I was 42 I had my left
Fallopian tube and ovary removed due to cysts and tumor. I have not had a period since Nov. Last
week I was treated for a vaginal bacterial infection, and the following week for urinary tract
infection. I experienced palpitations, chills, sweaty, and severe anxiety, with stiffening of feet and
jerky body movements. The physician's assistant said I should see a psychiatrist for anxiety
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disorder--I am on Prozac and take Zanex. When I came home from the , I needed to use the toilet
and lo and behold I have a period. I feel like I'm going crazy, I can't remember anything. Any
comments or suggestions? Thanks!
A: This is a normal pattern of bleeding in perimenopause.
Q: It has been one year since my last regular period and over six months since I last spotted. I
know that I am in menopause, although I have not had any blood analysis to show such. I have had
hot flashes, like most menopausal women for about four months or so. The problem is that when I
have a hot flash, I experience a racing feeling in my chest. My husband has been checking my heart
rate and blood pressure each time I have a hot flash. Each time my heart rate is elevated to
approximately 120 whereas it typically runs about 84 for me. Also, my blood pressure drops to
about 95/50 whereas it typically runs about 125/70. I am very concerned about this. Are these just
typical hot flashes or should I be concerned that it is something more serious?
A: These symptoms are typically for hot flush. The vasodilatation results in tachycardy and drop of blood pressure. No signs of heart .
Q: I had my last period in April. It is now late in May and I still haven't got my period. I am 44 years
of age. Last week I went on the 12th and had a urine pregnancy test from my GYN. It was negative.
I'm wondering if it is still possible that I am pregnant? I usually had my period every 3 weeks, to the
tee. But, I have to say that the last period was almost a week late, so are my concerns warranted? I
have been experiencing symptoms of peri-menopausal for several years now. I have tenderness in
the breasts, but otherwise I feel okay. The only thing that concerns me is the lack of menses and
that now I am not experiencing the hot flashes as much. Is all this normal?
A: The modern pregnancy tests are very sensitive. A negative test is almost certainly proof of no pregnancy. On this age ovulatory disturbances are frequently seen and this is probably the case.
Q: My wife just turned 50. She is perimenopausal. She has had a diminished interest in sex over the
last year, yet on the rare occasions we do have sex she has little trouble reaching orgasm and seems
to enjoy our lovemaking. The fact that she enjoys sex on one hand yet avoids it on the other seems
to me to be a contradiction that points away from her perimenopausal condition as a major factor in
her avoidance/lack of interest in sex. Or is it possible for a woman to experience a diminished desire
for sex due to her perimenopausal condition while at the same time showing no decrease in sexual
Perimenopause does not influence sex drive. But maybe she is tired, or somewhat depressive. That will influence sex drive, but not sexual satisfaction.
Q: I am a 32 year old woman. In the past few months my periods have been intermittent - one
month normal, the next month, all the symptoms but no period. I have also been experiencing
incredible hot flashes, mood swings, loss of sex drive & irritability. Am I too young to be
A: Never too young, but very unlikely. Just an annovulatory cycle I suppose.
Q: I read an answer you gave to a person stating she suddenly developed panic anxiety and muscle
aches and stiff neck, etc. I am also 48 and suddenly these same symptoms came on along w/
irregular periods which started first prior to panic, anxiety. Don't you agree that the mind and
physical are connected therefore, hormone fluctuations at perimenopause affects physiology and the
brain? I was taking ativan for panic and haven't taken meds for two months because my anxiety
subsided along w/ other symptoms. I don't believe my anxiety or panic would just disappear by itself
if I truly had nothing more than a psychiatric disorder. Too many women on message boards have
suddenly developed panic anxiety muscle aches, etc in their 40's. This certainly could be
perimenopause correct?
A: I disagree. Panic attacks and anxiety can mimic all climacteric symptoms. But they are not climacteric symptoms themselves. Perimenopause can aggravate these problems, but again panic attacks and anxiety are not perimenopausal symptoms and are not cured by taking estrogens.
Q: When / how much should I worry about memory loss? Is it normal to start losing some short term
memory when one is 41 years old? I am very healthy; had two weird period cycles (very short) last
year and am now back to normal. During the last year or so I find myself searching for words, using
wrong words--I have never had a problem with this before. Also I often can't remember simple
things like what I did yesterday or what I had to eat yesterday- without thinking a bit on it (I have to
think longer than I used to, before I come up with the answer). I'm worried about early menopause
and early Alzheimer's (one grandparent on each side apparently had Alzheimer's). Is there anything
I can do to improve short term memory? I am a legal secretary, keep track of a lot of details there,
and I have a very busy life. My mother thinks I'm just too busy and under too much stress. I am
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basically happy, and I sleep and eat well and try to exercise 2-3 times a week. I figure as long as my
job performance is not affected, the memory losses are probably not a problem - right?
A: No one can predict the future and there is no way to predict future memory. In your story nothing indicates early menopause. Maybe, your mother is the wisest. And your busy job is the cause. Alzheimer on an early age does exist and when there are really signs of is, you have to consult a specialist in neurology. But most people experience periods of bad memory without any linkage to Alzheimer.
Q: I am 43 years old, and was wondering what happens to a woman's sexual drive after 40? I use to
feel like I had a high sex drive and longed to have sex regularly. But now, I don't feel urges. What
do you suppose is happening wise?
Q: Have plant estrogens and progestins been shown to mimic human estrogens/progestins? Can
you describe the similarities, differences, benefits, and side effects in contrast to one another? I am
45 and have just started spotting before my period, which until now are still regular. I am also
having night sweats, hot flushes, with some dizziness, fatigue, and nervous flashes. Where in the
perimenopausal spectrum do you suppose I might fall?
A: Nothing changes with sexual drive when a woman passes the age of 40 years. You could be experiencing relational troubles. And a change in sex drive is largely determined by your relationship. Consultation of a sexuologist can be helpful. Or maybe a relational therapist
Hormones derived from plant sources are not different from hormones made in a factory. The structure of the compound is the only relevant item. A compound, has the same effect and side-effects regardless of the source. Some plant derived compounds are not characterized very well and the effects are not entirely known. This is the problem with unpurified plant extracts as in herbal medicines. Your situation is an early phase of perimenopause with ovulatory disturbances. Enough
Q: I am 46 years old and had a partial hysterectomy 3 years ago. My uterus, cervix were removed,
however I still have my ovaries. My annual check up this year, I was told my ovaries are about the
size of tiny grapes. Could these ovaries still be functioning and if so for how long? My Dr. seems to
think I could be starting menopause. How would I know? Then he said my ovaries can still function
for a few more years. I doubt this due to their size. I would really like to get the facts. I greatly
appreciate any information you can help me with, as I am very concerned.
estrogens are produced by your ovaries, but progesterone is lacking sometimes
A: Ovaries can contain functional cysts. That kind of cysts do produce estrogens. Cysts are often seen after hysterectomy mainly because of less blood supply to the ovaries. They can function very well during a long time. You will not know about their function as long as you have no complaints. Without complaints there is no need to worry about function of the ovaries. Wait and see what will happen.
Doctor, am I experiencing Perimenopause?
Q: I am 44 yrs old and haven't had a period for 3 months. Prior to this for two months had severe
hot flushes and could not sleep. Up until this time normal periods. I have been taking nighttime
primrose oil daily, hot flushes lessened. What do you think ?
A: This is perimenopause. With a change in menstrual pattern and sometimes hot flashes, sometimes no complaints. Maybe it is the primrose oil, but it could be estrogen production from your ovaries, which can solve the problem and a menstrual bleeding will come soon.
Q: I have been experiencing breast tenderness during the last month. My breasts feel "full and
heavy" and they hurt, specially my left breast. I had my period 6 weeks ago, but before that I
missed my period for 6 months. My periods are very irregular and this is not the first time that I
have missed my period for so long, but I have never experienced breast tenderness for so long. I
have been experiencing vaginal dryness also in the last months. Could breast tenderness and
vaginal dryness be a symptom of perimenopause? Other than breast tenderness and vaginal
dryness I haven't experienced any other symptoms.
A: Breast tenderness is a symptom of relative high estrogens or maybe low progesterone. With irregular cycle breast tenderness in the last weeks before a new period is frequently observed in perimenopause.
Q: I have been diagnosed with a fibroid tumor which is 12.5 cm. The dr. feels it is not large enough
to worry about, my periods have been very irregular for 3 years, could it be from the tumor? My G.P.
feels I am in perimenopause, she checked my estrogen and she said it was 10, my gynecologist
checked the FSH and said it was 13.2. I have no idea what these numbers mean. Can you please
help me? Is imperative for the blood work to be drawn only at a certain time of the cycle?
A: Fibroids are not responsible for irregularity of the menstrual cycle. They can cause bleeding problems but no irregularities. The blood work-up gives the impression of ovaries that do not function as good as many years ago, as is seen frequently in perimenopause. It can not predict the future cycles. In infertility clinics the lab test are done usually on day 3 of the cycle. But for testing ovarian function one can do this on any day.
Q: I'm 51 and have been perimenopausal for about 3 years. For the last 8 months or so I've been
experiencing frequent bleeding, averaging 11 to 15 days between 5- to 7-day cycles. Bleeding can
be quite heavy, accompanied by severe cramping. I had an aspiration just over a year ago, which
was clear. After so long a time in this phase, and with such irregular bleeding occurring, should I
consider it a normal ? Or would you suggest that there may be some abnormalities involved, like
fibroids? Would a hysterectomy be recommended if this were the case?
A: Short cycles of about 20 days (Including the bleeding days) are not unusual during this phase of life. When the bleeding problem causes anemia a treatment is recommended.. One can regulate the cycle with low dose contraceptive pills or by taking progestagens from day 15 to 24 or 26 of each cycle. Usually no uterine anomalies are found in this condition and no hysterectomy is advised when regulation of the menstrual cycle is easy to perform.
Q: I have been experiencing what I am now believing to be perimenopausal symptoms for almost 2
years now. I've been having headaches, I wake many times during the night (sometimes as many as
20 times a night), memory loss, irritability, fatigue, cold chills, onset of PMS symptoms, and
menstrual irregularity. I've been on a 28 day cycle, almost to the hour. For the past two years, my
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periods have been fluctuating from 22 to 27 day cycles. These symptoms started when I was 29.
How possible is it that I would be experiencing perimenopause at age 30?
A: The change of perimenopause before 30 is less than 1 in 1000. PMS is very likely to be the cause and treatment of PMS will probably be helpful.
Please check-out the PMS/PMDD collection for more information on your question.
Q: I am 36 years old, I have hypothyroidism and have quite unusual periods. I used to have normal
periods until I went off the pill when I was 22. When I went off the pill my periods ceased. We
wanted to have a baby so I went on fertility drugs, I did become pregnant, but my periods still never
returned after the birth of my baby. I was then diagnosed with hypothyroidism, and that still did not
help my periods. I have been on every birth control pill and progesterone and nothing has helped for
long. I will start another new birth control pill maybe have a period for 2 or 3 months then back to
nothing. I did at one time have excessive bleeding and the doctor found I had varicose veins on my
uterus, he just scraped them off. I am having more problems, I believe that I am in menopause but
my doctor tells me I am too young. I do not have periods, I have hot flashes and horrible night ,
vaginal dryness, and mood swings. I have had my hormone levels checked and the doctor says
everything is fine. Do you have any ideas or should I seek the advice of another doctor or an
A: This is not a simple problem to solve by e-mail. Probably you have a normogonadotropic normoestrogenic amenorrhea. This has nothing to do with menopause and should be analyzed by a gynecologic or reproductive endocrinologist.
Q: I am 64 yrs. old and I had a Hysterectomy at age 32. I was put on Premarin and the effects were
great. Now in the last month I wake up 2x a night sweating around my hair, neck , chest and I have
to get up and change my nightgown because it is so wet. When I had the hysterectomy my uterus
was taken out, but my ovaries are still in. Do you know any reason for this problem of night sweats?
This never happens in the day or evening time, it only happens when I am sleeping and I awaken
because I am so .
A: The possibility that your ovaries were until now is so extremely rare that it is not realistic to consider this as a cause. Women in your age can experience sometimes a hot flash. But with 2 times a month there is nothing to worry about and no need to take any measure.
Q: My girlfriend is 46, in the past 3 months after she went off the pill, she became depressed and
can not make decisions or think clearly. Could this be perimenopause? And is there anything she
should start doing to feel better and think clearly? Thanks.
A: No, it is not perimenopause. Depression is often seen at this age. Only when combined with hot flashes you can consider depression as a perimenopausal symptom. Otherwise, usual antidepressant therapy is required.
Q: Is forgetfulness a symptom of perimenopause? I'm 48 years old and at times my mind will go
completely blank when it comes to names?
A: No, it is not a perimenopausal symptom.
Q: I am 51 years old and postmenopausal. At present I am on Ortho-Prefest after experimenting
with Activella, Fem HRT, and changing to Ortho because of a terrible yeast infection with
excruciating itching. My gyno prescribed Traimconolone Acetonide Cream which did very little to
ease the itching. I asked for blood tests to measure my estrogen levels in order to decide if this is
the correct hormonal treatment for me, but she insists that is not necessary. Why not? She believes I
should stop the hormones altogether and see if that is the problem. If I do, I am a mess: sleepless,
weight gain, terrible mood swings, etc.
A: Persistent yeast infection is a very troublesome disorder. It is common in fertile women and in women with oral contraceptives, because yeasts contain receptors for estrogens. The postulated reason for persistence is an immunologic problem. Stopping estrogens is very seldom a proper solution. Also estradiol levels in your blood are not important. For this kind of problem we advise a monthly course of an antimycoticum (preferable oral) also when no itching is present. Sometimes the problem
cures it self and after a while no further monthly is necessary.
Doctor, What should I expect from HRT? Q: I am an Ob/Gyn and patients are asking me for
"Natural Estrogens" and natural progesterones for HRT. They understand the studies are not as
complete as other HRT but desire to stay away from Premarin. Could you please discuss these
medications and their use in HRT.
A: The request for "natural hormones" is nearly universal. But there is a lot of misunderstanding regarding this idea. What is natural? Compounds derived from nature? Or compounds from pharmaceutical companies that are structurally similar to hormones produced by the ovaries? Premarin is a mixture of many compounds, estrogens progestagens and even androgens. It is derived from the urine of pregnant mares and contains mainly oestronsulphate but also equilines that are natural for horses but
not for women. The estrogen activity of equilines is about the same as estradiol. So no difference in activity but difference in source. Natural estrogens (in women) are estradiol and estron. Micronized estradiol is a very popular prescription in Europe. With oral ingestion of estradiol, the estradiol is converted in the intestine to estron and absorbed as such and during the passage through intestine and liver most of it is converted to estronsulphate. Estronsulphate is the pool for the active compound
estradiol. So, no difference in the end result with estronsulphate tablets and micronized estradiol. Is estronsulphate now a natural estrogen or not? In premenopausal women the estron:estradiol ratio is about 1. With oral estrogen there are much higher levels of estron than estradiol. Is this natural? With transdermal estrogens, estradiol is absorbed through the skin and partly converted to estron. The ratio estron:estradiol is about 1 just as before menopause. This looks much more natural than all other
ways of administration. The same is true with progesterone. The only natural compound is progesterone. But this is absorbed very poorly both in the intestine as through the skin. Nowadays we have special products with micronized progesterone with a reasonable absorption pattern (Prometrium). This product is expensive and high doses are needed. With sedative and hypnotic side effects. because of the rather bad properties of progesterone in the early days progestagens are developed with the
same activity as progesterone, and mostly several other activities. This are the no natural progestins. Progesterone is developed also in a vaginal cream with good absorption pattern (Crinone). The natural progesterone creams (very popular among women) give no measurable progesterone levels in serum and are not protective for the endometrium.
Herbal remedies for perimenopausal symptoms is something for believers. The use of herbal remedies can be compared with religion. No proof, but many know for certain that it works. As an obgyn specialist in gynecology, I limit my comment to proven remedies. Only with red clover (and only with one brand, Promensil) a proof of benefit for hot flushes exists. When you wish an overview of non-western medicine you have to consult an alternative practitioner.
Please check-out this great article on your question called, Alternatives to Menopause Management. Reprinted with the kind permission from Andrew Dott, MD, MPH and the Institute of Endocrinology and Reproductive Medicine.
Q: I am a 35 year old female that had a partial hysterectomy 11 years ago. In December 2000, my
remaining ovary had to be removed due to recurrent painful ovarian cysts. I started HRT after
surgery, then began to have severe migraines within a few weeks (I have a history of migraines). My
MD suggested I discontinue HRT and see "what happens". The migraines went away. I then decided
to try herbal HRT, and went with a cream that had wild yam in it. On the 3rd day of use, I had to be
rushed to the ER with a severe migraine (B/P was 158/96). I discontinued this and waited a few
months, then tried Soy Isoflavones ... same result. Currently, I take 81 mg ASA, 800 iu Vit. E, Red
Clover, Black Cohosh, Calcium/Magnesium, and Nortryptaline every day. The hot flashes are almost
unbearable! How long can I expect these hot flashes to continue, and is there anything (other than
HRT) to minimize them?
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A: Migraine can be worsened by oral HRT. With transdermal HRT no worsening of migraine is seen. So, try patches with estradiol. Start with a low dose and increase the dose until reasonable success is reached.
Q: I'm menopausal, tried Prempo for 8 months, after 4 months started having panic attacks, feeling
depressed, some spotting for 3 months, finally stopped. Off Prempo Dr. wants me to start on patch
0.05 Estradern for a month then Provera 2.5 added the next month. US probe 8. Will bleeding start
up heavier when probe is 8 or has no barrier? Would staying off Estrogen, would the lining of uterus
go back to normal? Wouldn't I have had panic attacks and depression on Prempo sooner than 4
months? I'm 54 and FSH 56, estradiol 15.
A: First of all: what is the reason to take estrogens? Is there a proper indication (complaints? high risk of or osteoporosis) or is it because it is good for you? Without proper indication: stop and wait and see what happens. When you really need estrogens, try the estraderm or other patch, but do combine this with an adequate amount of progestagens as in the Combipatch. Adding Provera to continuous estrogens is possible but in higher dose on a sequential base. Or with the low dose of 2,5 but than
from the beginning. Otherwise bleeding will be a problem.
Q: What can be done about the weight gain associated with taking Premarin? I started taking it 4
months ago and have gained 5 pounds and rising steadily. I follow a healthy diet and walk 2-3 miles
almost daily. It's a struggle just to slow the weight gain much less stop it.
Weight gain is a problem of nearly all women, especially in this age group. But estrogens can not be blamed for it. There is a lot of scientific evidence that with the use of estrogens weight gain is less than without estrogens. Your healthy diet contains perhaps more kJ than necessary. And your exercise is maybe not strenuous enough.
Q: I am a 44 years old. In the past year, my periods have been heavier with cramping, but the
cramping is not every month. I spot anywhere from 2-weeks to a few days before my period. My
flow is very heavy at times to the point on 1 or 2 occasions I had to change a super tampax AND a
within 1-1/2 hours. Then it either slows or stops then becomes heavy again for about a day. My
periods also contain clots. My doctor wants to put me on prometrium 200mg. I will start taking it
14-days after the onset my period. I'll take it for 2 weeks then stop. She said I should start my
period. If things are the same after I take this, spotting, clots, she might do a D&C. What is the
purpose of this treatment for just 2-weeks? It doesn't appear I should have to worry about any
side-effects given I'm only taking it for 2 weeks? Can you please tell me what prometrium is and the
purpose of this treatment?
A: Your doctor has diagnosed an ovulatory disturbance. After ovulation the ovary secretes progesterone. A shortage of progesterone can cause bleeding problems. With 2 weeks of Prometrium the ovulatory cycle is mimicked and everything will be alright if the diagnosis is correct. Otherwise further investigation is necessary.
Q: I'm 38 years old, and I have been experiencing a lack of menstruation for about 11 months now. I
have been on Premphase for about a year and a half and have not truly had a period since June 6,
2000. I was told I had no estrogen so that is why I was put on the Premphase. The dosage that I have
been on is 0.625 mg/5 mg. In Nov. I was taking and extra dosage of Provera 10mg, so a total of
15mg, that was to see if I would start to menstruate. I also have not had a sex drive for quite a long
time and of course that is not good for my marriage either. I'm going to have a testosterone level
done on May 29, 2001 to see if that could be the cause for the no sex in my life. I'm kind of
confused! Why would I experience all the symptoms of menstruation but I don't menstruate? My
breasts get very tender and I experience my migraines and I have a bloated feeling all the time. I
know that the Premphase can cause some of these but, is there anything that you can tell me I
should try or do? I also would like to know am I really in the final stages of menopause? If you can
please tell me anything that I could do?
A: Premphase will induce withdrawal bleeds in about 90% of women. The other 10% are amenorrhoeic. That is not a problem at all. Breast tenderness indicates a high enough dose of estrogens. Migraines is a troublesome problem. This can be aggravated by oral estrogens, but not by transdermal estrogens. Maybe you can try an estrogen patch. Progestagens are also necessary with patches for 10-14 days each month!
Q: I am 46 years old and have an fsh count of 53, I have not had a period since February 2001 and I
am feeling extremely depressed and on edge all of the time. I tried PemPro and was not able to
tolerate it due to severe abdominal cramping and very sore breasts. What do you recommend?
A: First of all, try a course of progestagens (10 days 10 mg Provera). With a withdrawal your ovary is still producing estrogens. Without withdrawal no ovarian function is to be expected. With withdrawal, you can switch to low dose birth control pills or to monthly courses of 10 days of progestagen. Without withdrawal: continue HRT but with lower dose. Your sore breast suggest a high dose of estrogens, either endogenous or exogenous.
Q: I had a tvh/bso in 1996 due to endometriosis, and have been on 2 mg estradiol HRT since. I
have tolerated the HRT very well. Recently I began taking 2,000 mg./day Glucophage (Metformin)
for PCOS. Since the Metformin works in the stomach and intestine, I may not be absorbing the HRT
efficiently now. I started having hot flashes and dryness. The nurse suggested taking the oral HRT
pill and inserting it vaginally to increase the absorption. I thought the oral pills needed to be
processed in the liver to be effective? I do not use the patch because I swim daily. Is vaginal
insertion a good way to apply the hrt pill? Will it absorb into the body and deliver more estrogen to
the cells with vaginal application? Thank you for your answer.
A: Vaginal application of estrogens can result in very substantial estrogen levels but the dose is not easy to find. With the modern matrix patch, swimming is no problem. Other parenteral application like estradiol gel or intranasal estradiol are possibilities but not available in some countries. Another possibility is to increase the oral dose.
Doctor, What should I expect from HRT?
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Q: I am 55 years old and have been on Ortho-Prefest for approx. 10 months. Occasionally during
this time I have experienced some heavy bleeding that lasts for a couple days. This month, however,
after 3 months with no bleeding, I started my period again and it has continued for over two weeks,
and is still going. I have never had this happen. From the articles you have written, I now feel it may
be caused by the Ortho-Prefest. My question is, since I have been of the HRT for several months with
no reactions or side effects - why now?
A: Bleeding problems during the use of Prefest is observed in many . If you stop the medication for 3 months, then you can not blame the HRT for this bleeding. An investigation for postmenopausal bleeding is necessary. When still using the HRT, the bleeding is probably caused by the HRT. An endometrial biopsy is advised in this situation. But you can also try a course of sequential combined HRT first, instead of the intermittent combined therapy with Prefest. This regimen is continuous estrogens and
after 2 weeks combined with a progestagen for 10-14 days. With a regular cycle of withdrawal bleeds in that regimen, further investigation is not necessary. With irregular bleeding also after the change to this regimen, further gynecologic investigation is mandatory.
Q: I have been on Combipatch constant wear for a year now. I have slight discharge most of the
time (told that was to be expected first year to 18 months) - starting to get a little old now.... My
question is can I change this patch more than twice a week? The edges seem to become unstuck
and I'm afraid I'm not getting the dosage I'm supposed to be getting (or do the hormones come more
from the middle of the patch?) Seems like by the time the 3rd day has arrived, I'm ready for another
patch but they have you on a 3 day then 4 day schedule. Does it make a difference?
A: The combipatch releases the hormones in a nearly constant amount during the 3-4 days of application. During these 4 days a small decrease in the rate of hormone delivery occurs. On day 4 less hormone is released than on day 1. You can change the patch earlier. This will result in a somewhat higher dosage of estrogens because the lowest days are avoided, and it is much more costly. Rising the dose is not achieved with shorter application but by using larger patches. The amount of hormones
released is related to the surface of the patch.
Q: I am 52; periods every 3 months for past year. FSH 75. I take 10 mg Celexa. I am a runner,
excellent condition. Have several hot flashes a day; memory loss, fall asleep but wake every hour
and joint pain like I am 80. Also, NO LIBIDO. Lots of cancer history in family. Cardiac profile: Chol
198; LDL 115: HDL 63. Dr. today prescribed Estratest HS and Prometrium 200. You are my 2nd
opinion. What do you think? I do not want aggression, beard, low voice. Is this the easy way to
address my symptoms?
A: Libido is a matter of androgens and not a matter of estrogens, but above all the relationship with your partner is the most important factor regardless of hormone levels. For your perimenopausal problems, (hot flashes, bad sleep and joint pain) the prescription of your doctor is excellent. Estratest contains estrogen and androgen. The low dose androgen has only very rare the side effects of low voice.
Q: My oncologist advised me to ask my ob/gyn for a prescription for Effexor 37.5 mg. to treat hot
flashes due to having chemotherapy for breast cancer. He doesn't want me using anything with
estrogen. I questioned the clonadine patch, but he doesn't want me using that. I thought the patch
doesn't contain any estrogen. I looked up Effexor, but I could only see it being used for depression. I
was wondering how this drug reduces hot flashes? Thank you so much.
Clonidine does not contain any estrogen but will reduce the intensity of hot flashes. Anti-depressants, from the serotonin reuptake inhibitor class, have shown a proven effect in women with breast cancer treatment.
Q: I am taking oral HRT. I read an article that take oral HRT has to pass through the liver. Is this
true, and is there any evidence that it has any effect on the liver? Would a patch HRT with both
hormones be better?
A: All oral medicines taken have to pass through the liver. Just as all food compounds do. There is no evidence of any harm to the liver in . Only with severe liver disease caution is required. The patch is not better than tablets, the effect is the same. Oral estrogens induce in the liver the production of HDL-cholesterol and that is an extra benefit above the patch. But for treatment of hot flash both ways of administration are fine.
Q: I am a 58 year old woman. I was on different HRT therapies but not successful. Patches give me
heavy bleeding for weeks. Estrogen via pill form burns my stomach even after taking with meals.
Now the latest researches done say that HRT does not have any affect on heart. Breast cancer risk
increases. I have High blood pressure, high cholesterol and a history of and artherosclerosis. I
have currently borderline lesion in my artery. Do I take HRT or not to take?
A: The best for prevention of is a healthy diet, no smoking and enough exercise. Reducing weight is important in women with a high body mass. Estrogens are not appropriate in women with pre-existing heart disease at this time, but many researchers do believe that estrogens have an excellent beneficial effect in primary prevention of cardiac disease.
Q: I am going through perimenopause. I have no night sweats, but do have minor hot
flashes. I have no interest in sex, I feel very "flat" emotionally. I do have all of the "no's" that one
equate with not taking HRT...mother w/breast cancer, family history of high blood pressure,
grandmother died w/blood clots, , etc. Mother had minor form of osteo. First cousin had breast
cancer after taking HRT. I can't go on like this. Should I take HRT or some form of it?
A: When you have no climacteric complaints, there is no reason to take HRT. Especially not when you are at higher risk for breast cancer. The beneficial effect on the cardiovascular system can also be reached by a healthy diet, no smoking, normal body mass index and exercise.
Q: I am 48 years old, and had a complete hyst. 5 years ago. My doc put me on Premarin, but I
stopped taking it. Since then the hot flashes and night sweats are terrible. Is Premarin safe to take?
There is no history of breast cancer or other types of cancer in the family.
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A: The risk of breast cancer is determined by the total time span of estrogen exposure. The model that calculate the risk with HRT starts with the endogenous exposure from the ovaries from 12 to 50 years. After 50 years old, with 5 years use of HRT, a small increase of the number of women with breast cancer is seen. In your situation endogenous estrogen production stopped at 43 years. Without Premarin your risk should be decreased compared with women of the same age. But after 5 years of
Premarin, your risk is the same as women normally menstruating at 48 years. So continue estrogens, especially when you have complaints without them. A higher risk starts after 55 years.
Q: I am almost 47 years old. I have been experiencing Hot Flashes, night sweats, red hot ear lobes,
red hot fingers, inability to sleep, poor concentration and incontinence when I cough or sneeze hard
for the past 5 years. Vaginal dryness and painful intercourse has also been a problem. Last year one
of the NP's put me on 3months non stop LoEstrin, one week off, then resume the three months on,
one week off schedule. It was wonderful for the hot flashes, night sweats but not for the sleepless
nights and vaginal dryness and irritation. After about 9 months on this Loestrin schedule I started to
have some hot flashes and always resumed having them during one week off the pill. One year
later I went back for my yearly exam, pap and was scheduled with a different NP and told her my
symptoms so she stopped the LoEstrin schedule and started me on Climara 0.05 patch to be
changed every 7 days, and Prometrium 200mg. starting on the 13th for 12 days. I have not had hot
flashes, have slept a lot better, in fact too much sleep. I haven't noticed a change in vaginal dryness
, still dry and irritated easily. When I stopped the Prometrium as directed, I had pretty bad cramps,
back ache for 3-4 days with a mild period. Do I need the Prometrium? Can I take the 3 month
Loestrin and wear the Climara 0.05 patch? I always had a light period once I was off the Loestrin for
that one week and had very little cramping. I've had a really bad past 4 days since I stopped the
Prometrium, and really didn't have much energy while on Prometrium for those 12 days. Any
A: You are now on a normal HRT regimen. Estrogens (Climara) continuous with a monthly course of progesterone (Prometrium). It has no use to combine Loestrin with HRT. The combined dose of estrogens is much higher than needed and the combination will induce breakthrough bleedings. With the use of estrogens a periodic course of progesterone is absolutely necessary. Sometimes vaginal dryness does not disappear with estrogens and local therapy is needed. This is possible with local
Q: I am searching for a new gyn, and an estrogen therapy that will not make my breasts extremely
sore and tender. My previous physician, now retired, leaves me searching for a new gyn, and an
estrogen therapy that will not make my breasts extremely sore and tender. I am now trying FemHRT
and have just been placed on Actonel. My medical physician and his assistant have recommended
this therapy. I am also on atenalol for migraine/hpb control. Have been feeling LOUSY. Anxiety,
sleeplessness, waking up after 3 hrs of sleep and not being able to fall back asleep, mood swing, hot
flashes, irritable, and most disturbing, a feeling of being off balance several times a week, just as if I
am going to fall or pass out. And this follows usually with a bout of diarrhea. Its affecting my mental
health and outlook on day to day living and I crave sweets, chocolates, ice cream. Am about 30-40
pounds overweight and can't seem to accomplish/stick with anything. Also care for an 88 year old
Aunt, have no other family and feel that I am sometimes stuck. Is this what being 50 is all about?
A: FemHRT contains 5 micrograms ethinylestradiol and 1 milligram norethindrone acetate. After hysterectomy usually only estrogens are used, but sometimes in case of endometriosis one chooses to use the progestagens to because in a very rare situation endometriosis can grow again with estrogen only therapy. Sore breasts has to do with the level of estrogens and perhaps the kind of estrogen and the dose are not appropriate to you. I advice usually in this situation to use a low dose of estrogens
only (Premarin 0.3, or 1 mg estradiol or a patch with 30-40 micrograms estradiol. Another point to remember is your social situation. The care for your family asks lot of energy and the problems with a lack of energy is not covered by estrogens.
Q: 12 years ago I had a total hysterectomy at the age of 33. I am currently taking Estrace 2.5mg.
My hot flashes are so severe I can not sleep. I am losing a lot of sleep.
A: Sometimes the absorption of micronized estradiol is very low, or the activity of metabolizing enzymes is very high. In such situations higher doses are needed. But before doing so, maybe you can check the oestradiol level with the medication. Another solution is: switch to another estrogen: Premarin has a total different pattern of absorption and metabolism. Also patches can change the effect.
Q: I am 38 yrs old, happily married, with 2 boys and I have always had normal menstrual cycles,
accompanied by PMS, and still do. I have had a full medical workup and all tests are within the
normal range. I was diagnosed with depression 6 years ago and have been taking Serzone and
Wellbutrin. The medications have helped a lot but I would like to know if there are further ways to
treat my perimenopausal symptoms (night sweats, weight gain, hair thinning,)? My Dr. has upped
my dosage of Serzone to a total of 450 mil. a day and has no further treatment suggestions other
than psychological therapy. My main concerns are that in the last 6 months my PMS has gotten
much worse with strong feelings of worthlessness, crying jags, and trouble concentrating, etc. My
physical symptoms of major bloating, weight gain, and general lethargy have now become every day
rather than just monthly. I feel like I am out of balance and have a lot of stomach gas and
discomfort, I am also 10 pounds over my usual weight. I realize these symptoms are all related to
depression but my understanding is that being perimenopausal can exacerbate these symptoms. Do
you recommend herbal treatments? Vitamins B6, E, and such?
A: I can not recommend anything because as you state yourself already your problem is a problem of depression and not a perimenopausal problem. Psychological therapy is the only way to go. Vitamins and herbal therapy have no proven effect on these symptoms.
Q: I am 45 years old and around Thanksgiving I felt incompetent and that all the walls around me
were closing in. I was told that I had a mental disorder and at the beginning of what is know as
perimenopause. I was told to try Paxil and it seems to have taken away the insecurities I was
feeling, but I was hoping for something in the nature of herbs to ease this transition. Is there anyone
who can advise me?
A: Depression and perimenopause are not the same. It can be dangerous to categorize symptoms of depression as perimenopause, because treatment is quit different. Hormones are not antidepressants. For depression St. Johns Wort is taken by many and there is scientific evidence of its effect. But Herbal medicines like St. Johns Wort have side-effects!
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